Provider Demographics
NPI:1720107337
Name:DIBAL, DIEDRE A (APRN CNM)
Entity Type:Individual
Prefix:
First Name:DIEDRE
Middle Name:A
Last Name:DIBAL
Suffix:
Gender:F
Credentials:APRN CNM
Other - Prefix:
Other - First Name:DIEDRE
Other - Middle Name:A
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARPN CNM
Mailing Address - Street 1:825 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64124-2323
Mailing Address - Country:US
Mailing Address - Phone:816-474-4920
Mailing Address - Fax:816-474-4914
Practice Address - Street 1:825 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-474-4970
Practice Address - Fax:816-474-4914
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1339651031163W00000X
MO073851163W00000X
KS74337163WW0101X
KS64043176B00000X
MO073951176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100253000EMedicaid
MO257897009Medicaid
MO257897009Medicaid